Knowledge

1. Nutrition Therapy for Liver & Gallbladder Diseases

2. Objectives:
-understand nutritional modification in different
stages of liver diseases .
-discuss the importance of adequate nutritional
monitoring in end stage liver diseases
-support maintenance of as much normal liver
function as possible

3.  Metabolizes CHO, proteins, fat
 Synthesizes plasma proteins
 Stores vitamins and minerals
 Forms blood clotting factors
 Detoxifies drugs & toxins
 Produces & excretes bile
 Regulates hormone function
 Phagocytic activities
 Acts as reservoir for blood volume
Functions of the Liver

4. Liver Damage
1-Fatty Liver
Accumulation of fat in the liver,
Most common of liver disorders
Usually mild & reversible, but can progress to serious illness &
liver damage
Causes
Alcoholic liver disease
Exposure to drugs & toxic metals
Associated with
Obesity
Diabetes mellitus
Marasmus & kwashiorkor
Gastrointestinal bypass surgery
Long-term TPN

5. 2-Hepatitis
 Liver inflammation
 Results from any factor causing liver
damage
 Viruses A, B, & C
 Excessive alcohol
 Exposure to certain drugs & toxic
chemicals
 Some herbal remedies
© 2007 Thomson - Wadsworth

6. Types of viral Hepatitis
 Hepatitis A
 Extremely contagious
 Most common
 Cause: fecal-oral
 Hepatitis B
 Blood contact
 Sexual contact
 Vaccinations available
 Hepatitis C
 Blood contact
 Major cause of chronic hepatitis

7. Hepatitis
 Symptoms
 Mild & chronic may be asymptomatic
 Acute
 Fatigue, nausea, anorexia
 Pain in liver area
 Enlarged liver & jaundice
 Fever, headache
 Muscle weakness, skin rashes
 Elevated liver enzymes (ALT, AST)
© 2007 Thomson - Wadsworth

8. Acute Viral Hepatitis
Widespread inflammation of the liver
that is caused by hepatitis viruses A, B,
C, D and E
 Hep A: oral-fecal route
 Hep B and C: body fluids
 Hep D: occurs only in pts with Hep B
 Hep E: oral-fecal route; seen more often in
Asia, Africa, Mexico
Hasse JM et al. ASPEN Nutrition Support Practice Manual, 2nd edition, 2005

9. Hepatitis
 Treatment
 Supportive care; bed rest & appropriate diet
 Avoidance of substances that aggravate liver (alcohol, drugs or dietary
supplements that cause liver damage)
 Hepatitis A usually resolves without medications
 Hepatitis B & hepatitis C infections may require antiviral agents
 Nonviral forms: treated with anti-inflammatory & immunosuppressant
drugs
 Nutrition therapy
 May require high-kcalorie, high-protein diet to replenish nutrient stores
 Liquid supplements may improve nutrient intakes
 Small, frequent meals easier to tolerate for patients with anorexia or GI
discomfort
 Fluid & electrolyte replacement necessary in case of vomiting
 Sodium & fat restriction may be recommended
Nutrition & Diet Therapy, 7th Edition

10. •Lean meat & egg Wight
•Skim milk
•more fluid intake
•meals should be attractive and well cooked
• give boiled or grilled food
• more vegetable and fruit or high fiber diet .

11. Cirrhosis
Diffuse fibrotic bands of connective
tissue in response to inflammation
Distorts normal architecture and
function

12. Cirrhosis
 End-stage condition
 Scarring/fibrosis
 Irregular, nodular appearance
 Impaired liver function - can lead to liver failure
© 2007 Thomson - Wadsworth

13. Causes of Cirrhosis
 Hepatitis C
 Alcoholic liver disease
 Bile duct blockages
 All untreated types of chronic hepatitis
 Drug-induced liver injury
 Some inherited metabolic disorders
© 2007 Thomson - Wadsworth

14. Symptoms of Cirrhosis
 40% of people are
asymptomatic
 Initial symptoms
 Fatigue
 Weakness
 Anorexia
 Weight loss
 Later symptoms
 Anemia
 Blood clotting
impairment
 Susceptibility to
infection
 Jaundice & fat
malabsorption
 Ascites & varices
© 2007 Thomson - Wadsworth

15. Consequence of Cirrhosis
 Ascites
 Accumulation of fluid in the abdominal
cavity
 Due to
 Portal hypertension
 Reduced albumin
 Altered kidney function
 Abdominal discomfort & early satiety
 Weight gain
© 2007 Thomson - Wadsworth

16. Consequences of Cirrhosis
 Hepatic
encephalopathy
 Abnormal
neurological
functioning
 Amnesia, seizures,
hepatic coma
 Elevated blood ammonia
 Malnutrition & wasting
© 2007 Thomson - Wadsworth
•Diet in hepatic encephalopathy( failure) :-
-protein free diet
-adequate energy
-laxative
If the pt recover from the hepatic failure protein should be
given gradually with skim milk

17. Treatment of Cirrhosis
 Individualized according to disease severity & complications
 Supportive care
 Appropriate diet
 Avoidance of liver toxins
 Abstinence from alcohol
 Drug therapy
 Medications for portal hypertension, varices
 Diuretics
 Appetite stimulants
 Medications to reduce or control blood ammonia levels
 Nutrition therapy
 Customized for each patient’s needs
 Avoidance of substances that can cause further liver damage
 Enteral & Parenteral nutrition support as indicated
Nutrition & Diet Therapy, 7th Edition

18. Nutrition & Diet Therapy, 7th Edition

19. © 2007 Thomson - Wadsworth

20. Medical Nutrition Therapy
 Sodium & Fluid
 With ascites, need to restrict fluid and
sodium
 Vitamins & minerals
 Multivitamin supplementation
 Liquid form if patient has varices
 Enteral & parenteral
 Specialized enteral products high in
kcalories
 Parenteral if patient has obstructions,
bleeding, vomiting
© 2007 Thomson - Wadsworth

21. IV. Gallbladder Disease
 Gallstones (cholelithiasis)
 Gallbladder stores the bile made by the
liver
 Disorders of gall bladder & bile ducts
result in formation of gallstones
 Results from excessive concentration &
crystallization
 Two Types
 1. Cholesterol gallstones: majority of
cases of gallstones; composed primarily
of cholesterol; precipitation of
cholesterol out of solution eventually
forms stones
 2. Pigment gallstones: composed
mainly of calcium salt of bilirubin;
often result of bacterial infection
Nutrition & Diet Therapy, 7th Edition
Bile: solution of bile
salts, cholesterol,
proteins, phospholipids
& bilirubin

22. Gallbladder Disease
 Consequences of gallstones
 Many asymptomatic
 Other symptoms—usually occur
when gallstones block cystic duct
 Steady & severe pain
 Nausea, vomiting, bloating
 Symptoms mainly occur after meals,
especially fatty foods
 Complications
 Cholecystitis
 Peritonitis
 Blockage of common bile duct
 Infection
 Risk factors for gallstones
 Ethnicity
 Age & gender
 Pregnancy
 Obesity & weight loss
 Other risk factors
 Long-term TPN
 Medications
 High TG levels
 Treatment
 Low fat diet
 Cholecystectomy
 Non-surgical
 Capsule urso-deoxycholic acid
(cholesterol production; used on
small stones)
 Shock-wave lithotripsy (used on
few and larger stones)
Nutrition & Diet Therapy, 7th Edition

23. Jaundice
 Inability of liver to conjugate
bilirubin
 Bilirubin- bile pigment from
breakdown of Hb from RBC’s
by macrophages
 Skin & sclera – jaundice
 Excreted in urine – tea colored
urine
 Blocked from flow into
intestines – clay colored stools
Hyperbilirubinemia >1.2mg/dl

24. II. Cirrhosis
 End-stage condition resulting from
chronic liver disease
 Gradual destruction of liver tissue,
leading to scarring
 Progressive disease results in
increased scarring, few areas of
healthy tissue
 Impairs liver function & can lead to
liver failure
 Causes
 Alcohol abuse & hepatitis C
infection most common causes
 Chronic hepatitis
 Drug-induced
 Inherited disorders
 Bile duct blockages
 Consequences
 Initial disease: mild or
asymptomatic, fatigue,
weakness, anorexia, weight loss
 Later disease: decline in liver
function, anemia, impaired
blood clotting, increased
susceptibility to infection,
jaundice, fat malabsorption
 Advanced disease: disruption of
kidney & lung function
 Altered liver enzymes, bilirubin
levels
 Lowered albumin levels,
extended clotting times
 Elevated blood ammonia levels
Nutrition & Diet Therapy, 7th Edition

25. Cirrhosis
 Consequences (con’t)
 Portal hypertension
 Scarred tissue of cirrhotic liver impairs
blood flow through liver
 Resistance to blood flow increases
pressure in portal vein: portal
hypertension
 Collaterals & gastroesophageal varices
 Collateral circulation-smaller blood
vessels enlarge to allow alternative
pathway for blood flow because (in GI
tract & near abdominal wall)
 As a result, varices form (collaterals
become enlarged & engorged with
blood)
 Ruptured esophageal or gastric varices
can result in massive bleeding, often
fatal
 Ascites
 Accumulation of fluid in the
abdominal cavity; indicates critical
stage of liver damage
 Thought to be consequence of
portal hypertension, reduced
albumin synthesis & altered kidney
function
 Hepatic encephalopathy:
characterized by abnormal
neurological functioning
 Changes in personality, mental
abilities & motor function
 Amnesia, seizures
 Hepatic coma
 Elevated blood ammonia levels
 Malnutrition & wasting
Nutrition & Diet Therapy, 7th Edition